Tuesday, March 19, 2013

The contribution research can make to care

Research and
academic scholarship are not ivory tower luxuries. They have the potential to
transform the care you offer, and to help you move from OK to good, and from
good to excellent

On September 1st
1967, the Nobel Prize-winning civil rights leader Martin Luther King said, in a
speech to the American Psychological Association: “There are some things in our
society, some things in our world, to which we … must always be maladjusted if
we are to be people of good will”.

There’s plenty
going on right now that we should be maladjusted to – and there’s plenty of
ways that researchers at the University of Liverpool, in the Institute of Psychology,
Health and Society, can help that process of creative maladjustment, that
journey to excellence.

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The social and political context

Our public health
researchers explore how our health and well-being are intimately related to
social, economic and even political issues.

So Ben Barr and
David Taylor-Robinson have revealed how economic circumstances affect our
mental health, and have found
how around a thousand people have taken their own lives as a directly
attributable result of the economic recession since 2008.

They – Ben and
David – have also revealed
that the cuts in local authority spending are falling hardest on the poorest –
with central government funds withdrawn most severely from the most deprived
communities.

This matters,
because our research starts in the social and human realities of our clients’
lives. We therefore understand that our core business is much less about
treating illnesses and much more about promoting well-being.

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Diagnosis

In 2006 I published a very
simple paper with Erika
Setzu, Fiona Lobban and Peter Salmon. It was simple because all we did, in
essence, was interview people about how they had ended up in mental health
care. One quote is worth repeating at length:

Client: “I started to hear
voices, but they were not nice voices, they were horrible.”

Interviewer: “Did you recognise
them?”

Client: “It was the man that
abused me … I met this man that was a builder, in construction, you know? And
he said that he wanted to give me a job, but they were all lies, he was trying
to con me. He took me back to his house, he locked the door and he had sex with
me. … And then other voices as well. I went to … hospital and the nurses were
very good to me.”

Interviewer: “When you went
to hospital what did they say it was wrong with you?”

Client: “Schizophrenia,
paranoid schizophrenia.”

Interviewer: “What do
you think personally?”

Client: “What do you mean?”

Interviewer: “Do you think it
is what you’ve got?”

Client: “Oh yes, that’s what
I have got.”

The conclusion in my mind is
rather simple. This really does look as if it’s the normal, understandable,
human response to horrible trauma … mislabelled as “illness”.

This man clearly needs help –
hearing the voices of your rapist must be hugely distressing (although also
pretty common). And I think the care he received may well have been
admirable; he says the “nurses were very good” to him.

What I object to is the idea
that this experience, and the experiences of many millions more, in any sense
resembles an “illness”.

We need to recognise the
pernicious danger of thinking about such experiences as if they were symptoms
of ‘illness’ – with the consequent stigmatising attitudes, harmful ‘treatments’
and, equally, avoidance of the key issues; in this case, sexual violence.

We should be ‘creatively maladjusted’ to this creeping medicalization of human distress. Right now,
the American Psychiatric Association is preparing to publish the latest version
of its diagnostic manuals – DSM-5. It seems clear that this manifestation of
the medicalization of human distress will be more paradoxically illogical, more
invalid, more stigmatising, and more pervasively likely to pathologise
normal human reactions than ever before.

We need to
ensure that alternative voices of reason are heard. People have the right to be
concerned. We need to be cool, to be elegant, to be evidence-based and we need
to be humane. But we need to make it clear that we are concerned about the
consequences of unrestrained diagnostic labelling.

We, at the
University of Liverpool, in the Institute of Psychology, Health and Socuiety,
are working with you to develop alternative, better, ways of understanding your
clients’ distress, without inappropriately labeling them.

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Humane care

When it comes to
treatments, there are again things to which we should be maladjusted.

We must refuse to tolerate the
cruel, inhuman and degrading treatment of people in psychiatric care. This
includes the appalling inhumanity described – correctly – by the United Nations
as "akin to torture".

But such extremes are also
supported by everyday inhumanity – and by the inadequate, cruel and uncaring
treatment experienced every day and in many (if perhaps not all) settings. On
the same day I read the UN report, a man wrote to me describing his experiences
of psychiatric 'care'. The whole incident is traumatic; from the initial
involuntary admission (in handcuffs, by the police) to discharge. I was
particularly struck, however, by the everyday inadequacy of the inpatient stay.
This won't be terribly surprising to people working in mental health care...
but the fact that this account will be recognised speaks to its truth.

My correspondent reported;
"... Rather than engaging with the patients on the ward, the staff
instead shepherded them around like sheep with bullying commands, threats of
‘jabs’ (injections), and removal to an acute ward elsewhere in the hospital, if
they did not co-operate. The staff also stressed medication rather than
engagement as a way of controlling the patients.

And the staff
closeted themselves in the ward office, instead of being out and about on the
corridors and in the vestibule where they should have been. The staff wrote
daily reports on each patient on the hospital’s Intranet system; these reports
were depended upon by the consultant psychiatrists for their diagnoses and
medication prescriptions, but were patently fabricated and false, because the
staff had never engaged or observed properly the patient they were writing
about in their reports. The psychiatrists themselves were rarely seen on the
ward, and only consulted with their patients once a week."

I certainly
recognise this account. It doesn't represent absolutely all psychiatric
units... but it isn't bizarre or unrepresentative. It reflects - in psychiatric
rather than acute medical care - the findings of the Francis Report into uncaring and inhumane treatment in the Mid-Staffordshire
NHS scandal. And we should absolutely refuse to accept it. I don't want to
accept this as the status quo. And we should absolutely refuse to accept it. I
don't want to accept this as the status quo.

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Research

So… what can
research offer?

Another of my
colleagues here at the University of Liverpool, Professor Richard Bentall – in
his book ‘doctoring
the mind’ - has analysed how traditional treatments, especially high-dose,
long-term use of so-called anti-psychotic medication have hardly improved
real-world outcome.

Indeed, Richard,
and the US journalist, Robert
Whitaker, have demonstrated pretty convincingly that long-term (in the
short-term, the situation is ifferent) anti-psychotic medication can impede
recovery.

So, instead, we
have developed alternatives.

I and colleagues
at the University of Liverpool – of course, in collaboration with others have
been involved with many clinical trials. I accept that RCT’s – randomized
controlled trials – have their limitations. I accept that CBT – cognitive
behavioural therapy – is not the only fruit. And I confess… we entitled our
papers with diagnostic labels such as ‘schizophrenia’ and ‘bipolar disorder’ –
hey!, I, too, am the product of the social context!

But the point is
that we’re developing alternatives – in my view more effective, more
scientific, more humane alternatives – to old-fashioned psychiatric care.

Indeed, some of
our RCTs don’t even involve CBT. More recently we’ve been collaborating with
Lancaster on the development of relapse prevention
strategies. We’re also working to improving access to primary-care
psychosocial interventions… not only in Liverpool, but across the world. In Pakistan,
my colleague Atif Rahman is developing accessible psychosocial support for
women in rural communities following the birth of their children. We’re even
investigating ‘body psychotherapy’ – physical therapies… but with a very
different ethos to traditional ‘physical interventions’.

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Well-being

And our
investigation of alternatives can be quite radical. The now ubiquitous

5 ways to
well-being, seen across the City, was originally developed by a team of
experts including Sam Thompson an honorary Research Fellow here at the
University (he used to work here until taking up a place as a trainee clinical
psychologist… which is, of course, a wonderful thing). 5 ways to well-being
offers practical, everyday, opportunities to protect and promote your mental
health.

And… it fist with
radical approaches to measuring outcomes, such as the BBC well-being scale, a
universally applicable measure of well-being.

All developed
through the University of Liverpool Institute of Psychology, Health and Society.

So…. We should
refuse to accept sub-standard care.

And… we at the
university are actively working, with you, to develop and evaluate
alternatives.